- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.95 / $19.95 / $19.95
| Facility | 26 | $19.95 | $19.95 | $19.95 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $74.13 / $229.09 / $234.42
| Facility | TC | $74.13 | $229.09 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.90 / $39.81 / $87.10
| Professional | | $30.90 | $39.81 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.00 / $12.88 / $33.11
| Professional | 26 | $10.00 | $12.88 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $19.95 / $25.70 / $45.71
| Professional | TC | $19.95 | $25.70 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $40.74 / $66.07 / $102.33
| Professional | | $40.74 | $66.07 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.59 / $20.42 / $29.51
| Professional | 26 | $12.59 | $20.42 | $29.51 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.18 / $44.67 / $66.07
| Professional | TC | $28.18 | $44.67 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $42.66 / $64.57 / $114.82
| Professional | | $42.66 | $64.57 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.45 / $22.91 / $38.02
| Professional | 26 | $14.45 | $22.91 | $38.02 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.84 / $44.67 / $79.43
| Professional | TC | $28.84 | $44.67 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $46.77 / $74.13 / $109.65
| Professional | | $46.77 | $74.13 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.79 / $21.88 / $33.11
| Professional | 26 | $14.79 | $21.88 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $33.11 / $51.29 / $74.13
| Professional | TC | $33.11 | $51.29 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $44.67 / $63.10 / $147.91
| Professional | | $44.67 | $63.10 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.13 / $20.42 / $38.90
| Professional | 26 | $14.13 | $20.42 | $38.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.90 / $39.81 / $85.11
| Professional | TC | $30.90 | $39.81 | $85.11 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $9.77 / $10.72 / $13.18
| Facility | 26 | $9.77 | $10.72 | $13.18 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $23.44 / $25.70 / $28.84
| Facility | TC | $23.44 | $25.70 | $28.84 |